Insurers Pocket Copay Assistance Funds Meant to Defray Patient Drug Costs, Leaving Patients Financially Devastated

For 16 years, Larry Gruber, a fitness coach from Wilton Manors, Florida, relied on a manufacturer coupon card from Amgen查看公司主页 to afford Enbrel查看药品详情, a psoriatic arthritis (搜索)搜索该疾病 medication costing more than $7,700 per month. Each year, the coupon — worth thousands of dollars — counted toward his health insurance deductible and out-of-pocket maximum, typically allowing him to meet that threshold by February and receive the drug at no cost for the remainder of the year. That changed in 2024 when his new insurer, Oscar HMO of Florida, deployed a copay accumulator program that pocketed the assistance and required Gruber to satisfy cost-sharing requirements entirely on his own.

"If Oscar Health had applied Amgen查看公司主页's coupon toward Gruber's cost sharing, he would have been on the hook for about $3,000 in covered services. Without it, he had to use his savings to meet the plan's $10,600 out-of-pocket maximum," according to reporting from KFF Health News. Gruber described the experience bluntly: "The real insult here is that they're taking the money that's intended to help you. I feel desperate, pressed against the wall, and squeezed."

How Copay Accumulator Programs Function

Copay accumulator programs — also called copay adjustment programs — allow health insurers to exclude manufacturer copay assistance from counting toward a patient's annual deductible and out-of-pocket maximum. Over the past decade, an increasing number of commercial health insurers have adopted such strategies to reduce their prescription drug costs, according to Avalere Health, a consulting firm.

Matt Choffin, Florida market president for Oscar Health (搜索)搜索该公司, did not comment on Gruber's specific case but stated the company uses copay accumulators to manage rising medical and prescription costs and "to keep monthly premiums as low as possible."

The practice has drawn sharp criticism from patient advocacy groups. "They're collecting the money twice and they're hurting patients," said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. Schmid questioned the insurer's logic: "Why does it make a difference to Oscar if they get the money from a drug company or, you know, his mother or him? They're still getting the money."

The Battle Between Insurers and Drugmakers

The pharmaceutical industry and insurance companies offer competing narratives about copay assistance. Sarah Ryan, a spokesperson for Pharmaceutical Research and Manufacturers of America (PhRMA), said copay assistance helps patients access medications free of charge or at reduced cost. "Health insurance is supposed to protect patients," Ryan said, adding that insurers and pharmacy benefit managers that refuse to count copay assistance toward cost sharing are "leaving patients facing unexpected costs and disrupting their care."

Insurers counter that manufacturer coupon cards drive up premiums and steer patients toward higher-priced brand-name drugs instead of less-expensive generics. Sean Dickson, a senior vice president for AHIP, the insurance trade association, stated: "Drugmakers offer short-term 'discounts' to justify overcharging Americans in the long term, driving up healthcare costs for everyone. Research shows limiting copay coupons can reduce premiums and lower consumers' out-of-pocket costs."

Rachel Klein, deputy executive director for The AIDS Institute, noted that insurers already possess multiple tools to control costs without intercepting patient assistance. "They are the ones making the decisions," Klein said. "Now the individual is left trying to figure out how they're going to pay for it."

Patients Most Affected

Patients taking brand-name specialty drugs for autoimmune disorders, multiple sclerosis, diabetes, HIV, and cancer are most likely to encounter copay accumulator programs. For Gruber, who has no medically equivalent generic alternative to Enbrel查看药品详情, the financial impact has been severe. When diagnosed in 2010, he could not shake hands or lift his knee to get into bed. The weekly injections, required for life, prevent his joints from stiffening and allow him to work as a fitness trainer.

After Oscar Health (搜索)搜索该公司 initially counted his coupon card toward his deductible — then reversed course — Gruber began rationing his injections, taking them every other week instead of weekly. By May, he had depleted his savings to pay for the medication. "It's the first thing I think of when I wake up in the morning," Gruber said. "If this happens every year, it would be financially devastating."

Regulatory Landscape: States Act While Federal Action Stalls

Regulation of copay accumulator programs has fallen primarily to states, which oversee individual and small-group plans sold on the Affordable Care Act marketplace. For 2026, nearly 40% of ACA marketplace plans include such programs, according to a review by The AIDS Institute. In Florida, 10 of the 16 insurers selling marketplace plans use copay accumulators.

The first state laws banning copay accumulators were adopted in 2019. Today, 26 states, Washington, D.C., and Puerto Rico have enacted laws either banning the programs outright or prohibiting them for drugs without a generic equivalent. Colorado extends the prohibition to drugs without a biosimilar. Gavin Clingham, public policy director for the Alliance for Patient Access, said: "The goal is to build upon that progress at the federal level and to continue to drive this momentum forward."

Federal regulation, however, remains at an impasse. A federal court in 2023 struck down a Trump-era policy that had permitted insurers to use copay accumulator programs, causing the Department of Health and Human Services to revert to an earlier rule restricting their use to brand-name drugs with a medically appropriate generic equivalent. The Biden administration pledged to address the issue in future rulemaking, but HHS has yet to act.

Bipartisan legislation — the HELP Copays Act — would require financial assistance to count toward deductibles and out-of-pocket costs on federally regulated plans, including much employer-sponsored coverage. Schmid acknowledged the bill "has not gotten enough traction on the Hill yet."

Christopher Krepich, a Centers for Medicare & Medicaid Services spokesperson, said HHS, along with the Departments of Labor and the Treasury, intend to address whether copay assistance must apply toward health plan cost sharing. Until then, "the Departments do not intend to take any enforcement action against health insurance issuers or group health plans based on their treatment of such manufacturer assistance."

For patients like Gruber, the consequences are immediate and personal. The extra expense means no vacation this year, and the savings intended for a home purchase are now diverted to medication costs — a financial trajectory he described as potentially devastating if repeated annually.